'When you hear hoofbeats, think of horses not zebras' - the old adage is well-known to GPs but what should you do when faced with a zebra, not a horse? Consultant cardiologist Professor Robert Tulloh and GP Dr Louise Tulloh kick off our new series with their advice on how to catch Kawasaki disease in general practice.

The new chair of the BMA’s GP Committee, Dr Richard Vautrey, has given his first interviews since his appointment, speaking about potential mass list closure, the future of the QOF and practices declaring ’black alerts’

Whatever the result of the ballot, the Government and NHS England can’t ignore the fact that GPs right around the UK, and England particularly, are saying ‘something has to give, something has to happen’.

We are not advising practices one way or the other, because we genuinely want to know what they would do. What we don’t want to happen is to be in a situation as we saw with the pension’s dispute: large numbers of people said that they were prepared to take action but when we pressed the button actually they weren’t prepared to do it in the end.

We need to be absolutely confident that this is what practices want to do. We then have to go through a very formal process of looking at the trade union legislation for taking industrial action, which is complex; we would have to involve the wider-BMA in that.

We will pursue that if it is what practices genuinely feel that is what they are up for and want us to pursue.

There will then be a subsequent formal industrial action ballot, should that be needed based on the results of the survey we’re doing at the moment.

But it’s a negotiation; we will wait and see what the results of that negotiation is, as we do any year.

We will look at the whole package and try to get the best deal possible for GPs.

There’s no will from the conference to do away with QOF all together.

Vautrey on indemnity…

We are in active dialogue at the moment with the Department of Health and with the medical defence organisations about how we can have a new system that recognises the quantum [increase in costs] that will come as a result of the discount rate changes.

We’ve made it very clear to the Department of Health, even in the last few days, that this has to happen quickly because there is a real risk that medical defence organisations will be forced to put up their rates to a level that will make it untenable for many GPs to work, or to do the number of sessions that they were able to do.

If they do that, that will end up with a winter crisis like no winter crisis we’ve had before.

Vautrey on affecting change…

Everybody knows general practice is in crisis, there’s been a decade of underinvestment.

The Government have acknowledged that, NHS England have acknowledged that.

We know there’s a workforce crisis, I was doing an interview this morning with local radio where people were phoning in to say we can’t get an appointment with our local practice. And that’s clearly because there aren’t enough GPs, practice nurses or support services around those practices.

And practices are struggling to deliver a service to their growing population with growing needs.

We need to see the investment there and a change all the way across the system, a change of philosophy at Government level so that they genuinely do invest properly in general practice.

We need a change in NHS England so they ramp up the support and engagement and necessary changes to deliver what we need in general practice: an expanded workforce; good quality premises to work in; the right working conditions; protected workloads for GPs, so they’re not burning themselves out and leading themselves to get ill while trying to do the best for their patients.

There have already been big changes: the scrapping of the avoiding unplanned admissions DES, sickness payments, scrapping of CQC fees for practices.

What we haven’t get done is address the fundamental issues of the sustainability of workload management in practices.

We’re making changes around things like the work shift into general practice from secondary care, through changes in the standard contract. That means when a patient is seen in the hospital they get a fit note in the hospital, they don’t get sent back to the practice.

There’s a lot that can happen there, but we nevertheless we need a step change in the funding and in the workforce commitments and recurrent funding to support that.

The LMCs conference focussed on workload and workload limits, and again at the ARM we again talked about a system where practice can alert the wider system when they’re at capacity a black alert system.

That is work we’re going to be doing this year. One of the key tasks is building on the work we did 18 months ago where we talked about developing hubs, and defined workload limits, and finding ways that practices utilising the existing contract and contractual mechanisms, can themselves define their capacity.

So for instance we’ve seen practices starting to work together to develop a hub-based system so that provides the pressure valve where patients can be sent and directed should the practice itself have reached the capacity limit for any one particular day. That might be one way we start to develop the system in the future.

But we need to be very careful. We can’t make a very simplistic assessment of whether a 30 minute quality consultation with a patient with complex needs is any better or worse than ten three minute consultations with patients over the phone. When you start to talk about numbers, it gets very difficult. Speaking to ten patients over a half an hour period can be very stressful.

The legal situation is that if you’re a lead employer area, you have to adopt the contract, if you’re not in a lead employer area then you don’t. That’s the legal situation.

But the reality is whether you’re in a lead employer area or non-lead employer area, it’s good practice to ensure that your trainee is not exploited.

You protect them, and you protect them from themselves. There’s always the risk when a trainee wants to do their best, they want to give time to their patients and potentially they do stay longer and want to get things done. But equally the practice needs to make sure they are working in such a way, and have an appointment frequency that allows them avoid doing more than 40 hours on a regular basis.